DEPARTMENT OF INSURANCE



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DEPARTMENT OF INSURANCE

STATE OF NORTH CAROLINA

FORM E

PRE-ACQUISITION NOTIFICATION FORM

REGARDING THE POTENTIAL COMPETITIVE IMPACT

OF A PROPOSED MERGER OR ACQUISITION BY A

NON-DOMICILIARY INSURER DOING BUSINESS IN THIS

STATE OR BY A DOMESTIC INSURER

GENERAL INSTRUCTIONS

Transactions subject to North Carolina General Statute (“G.S.”) 58-19-15(a) may not be entered into unless the acquiring person has submitted a pre-acquisition notification with the Commissioner on a Form E.

Form E is a guide to be used in preparation of the notification required by G.S. 58-19-15(f); it is not a blank form to be filled in. A Form E statement is attached.

Detailed instructions for the preparation and filing of a Form E statement are contained in G.S. 58-19-15, G.S. 58-19-75, G.S. 58-19-80, G.S. 58-19-85, and G.S. 58-19-90.

DEPARTMENT OF INSURANCE

STATE OF NORTH CAROLINA

FORM E

PRE-ACQUISITION NOTIFICATION FORM

REGARDING THE POTENTIAL COMPETITIVE IMPACT

OF A PROPOSED MERGER OR ACQUISITION BY A

NON-DOMICILIARY INSURER DOING BUSINESS IN THIS

STATE OR BY A DOMESTIC INSURER

_______________________________________________________

Name of Acquiring Person (Applicant)

_______________________________________________________

Name of Other Person

Involved in Merger or Acquisition

Filed with the Insurance Department of North Carolina

Dated _____________, 20____

Name, Title, Address and Telephone Number of Individual to

Whom Notices and Correspondence Concerning this Statement

Should be Addressed:

________________________________________

________________________________________

________________________________________

________________________________________

ITEM 1. NAME AND ADDRESS

State the names and addresses of the persons who hereby provide notice of their involvement in a pending acquisition or change in corporate control.

ITEM 2. NAME AND ADDRESSES OF AFFILIATED COMPANIES

State the names and addresses of the persons affiliated with those listed in Item 1. Describe their affiliations.

ITEM 3. NATURE AND PURPOSE OF THE PROPOSED MERGER OR ACQUISITION

State the nature and purpose of the proposed merger or acquisition

ITEM 4. NATURE OF BUSINESS

State the nature of the business performed by each of the persons identified in response to Item 1 and Item 2.

ITEM 5. MARKET AND MARKET SHARE

a) State specifically what market and market share in each relevant insurance market the persons identified in Item 1 and Item 2 currently maintain in that state.

b) Provide historical market and market share data for each person identified in Item 1 and Item 2 for the past five years and identify the source of such data.

c) Provide information to support whether the proposed acquisition or merger, if consummated, would substantially lessen competition.

If the proposed acquisition or merger would substantially lessen competition, provide justification of why the acquisition or merger would not create a monopoly in the state.

For the purposes of this item, market means direct written insurance premium in this state for a line of business as contained in the annual statement required to be filed by insurers licensed to do business in this state.

ITEM 6. SIGNATURE AND CERTIFICATION

Signature and certification on the attached form.

SIGNATURE

Pursuant to the requirements of North Carolina General Statute 58-19-15,

__________________________ has caused this Statement to be duly signed on its behalf in the

(Name of Applicant)

City of _____________________ and State of __________________, on the _______ day

of ___________________, 20 _____.

(SEAL) ________________________

(Name of Applicant)

By ________________________

(Name)

________________________

(Title)

Attest: _____________________________________

(Signature of Officer)

_____________________________________

(Title)

CERTIFICATION

The undersigned deposes and says that (s)he has duly executed the attached Statement dated

the _______ day of ______________, 20 ________, for and on behalf of

______________________________________ that (s)he is the ____________________

(Name of Applicant) (Title of Officer)

of such company and that (s)he is authorized to execute and file such instrument. Deponent further says that (s)he is familiar with such instrument and the contents thereof, and that the facts therein set forth are true to the best of his/her knowledge, information and belief.

Signature ________________________

Type or Print ________________________

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